Population Health Institute
Translating Research for Policy and Practice

Safety Planning and Follow-up

Note: This strategy is for anyone working in crisis support and is not limited to those with a formal counseling or therapy title.

 

Strategy Description

Staff trained in crisis support should implement a safety planning and follow-up protocol that includes discussing making the environment safe, such as securely storing firearms. Evidence shows that safety planning and telephone follow-up calls reduce suicidal ideation, hopelessness, and psychological pain, in addition to engaging with treatment services.

Action Steps Based on the Literature 

  1. Develop a standard safety plan template: A Safety Plan is a prioritized written list of coping strategies and sources of support for helpseekers at an elevated risk for suicide or experiencing a suicidal crisis1. The plan should be concise, realistic, and individualized1. It is essential that the safety plan is flexible, and most importantly, keeps the helpseeker safe2. Written safety planning protocols for staff are important for consistency3.
  2. Complete collaboratively with the helpseeker: Actively listen to, empathize with, and engage the helpseeker during the completion of the safety plan. If it has not been discussed yet, ask the helpseeker if they have access to a firearm. If they have access to a firearm, it’s important to discuss how to keep the environment safe1. When discussing how the plan will be used, explain to the patient that it is a tool designed to assist them. Although there are specific steps to follow, they should seek the level of support that will ensure their safety. Inquire where they plan to store the plan to keep it secure and easily accessible1.
  3. Implement follow-up conversations to review safety plan: Safety planning plus follow-up contact with people with an elevated risk for suicide or who have attempted suicide has been shown to reduce suicidal ideation and behaviors and increase engagement in treatment5. Structured follow-up as a part of safety planning is widely used and effective within the Veterans Health Administration. Veterans who visited an emergency room with a suicide-related concern who engaged in safety planning and received follow-up phone calls were half as likely to exhibit suicidal behavior and more than twice as likely to attend treatment during a six-month follow-up period compared to those who received usual care4. For helpseekers at elevated risk, follow-up calls help minimize ideation, hopelessness, and psychological pain6. The basic structure of a follow-up call should include assessing the individual’s current well-being and suicide risk, collaboratively reviewing and updating the safety plan as necessary, coordinating care with other providers, and enhancing access to needed services or additional resources6. Establish a clear program protocol for staff trained in crisis support who conduct follow-ups. While the details of the follow-up plan may vary depending on the current level of safety and the follow-up goals, the overall approach should remain consistent. Develop a safety plan and use it to guide follow-up calls for helpseekers experiencing suicidal or homicidal thoughts, including a plan for reducing access to firearms6.
  4. De-escalate the situation for helpseekers when possible: It’s important for staff trained in crisis support to remain aware of their own reactions or biases to ensure they are properly assessing the individual for imminent risk and using emergency services only when all efforts to collaborate and use less invasive interventions, such as lethal means counseling and safety planning, have been unsuccessful7. Safety planning is not appropriate when there is a suicide attempt in progress (but safety planning may be engaged while emergency/support services are on the way or being confirmed), when imminent risk is present and cannot be de-escalated, or when the individual is under the influence, disconnected from reality, or experiencing profound cognitive impairment7.

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Evidence Summary

A safety plan is a structured way to help those who may have an elevated risk of suicide to identify their warning signs, strategies for safety, and resources for support1. The plan should be concise, realistic, and individualized1. It is also essential that the safety plan is realistic and flexible, and most importantly keeps the individual safe2.

This process of creating a safety plan involves actively listening to, empathizing with, and engaging the helpseeker. Safety planning is not appropriate when there is a suicide attempt in progress (but safety planning may be engaged in while emergency/support services are on the way or being confirmed), when imminent risk is present and cannot be de-escalated, or when the helpseeker is under the influence, disconnected from reality or the individual is experiencing profound cognitive impairment1. Written safety planning protocols for staff are important for consistency3. When discussing how the plan will be used, explain to the helpseeker that it is a tool designed to assist them. Although there are specific steps to follow, they should seek the level of support that will ensure their safety. Inquire where they plan to store the plan to keep it secure and easily accessible1.

Safety planning and telephone follow-up calls have been shown to reduce suicidal behavior and increase treatment engagement4. Structured follow-up as a part of safety planning is widely used and effective within the Veterans Health Administration5. Patients who received this intervention were half as likely to exhibit suicidal behavior and more than twice as likely to attend treatment during a six-month follow-up period compared to those who received usual care5. For helpseekers with elevated risk, follow-up calls help minimize ideation, hopelessness, and psychological pain6. The basic structure of a follow-up call should include assessing the individual’s current well-being and suicide risk, collaboratively reviewing and updating the safety plan as necessary, coordinating care with other providers, and enhancing access to needed services or additional resources6. One recommendation is to establish a clear program protocol for staff conducting follow-ups. While the details of the follow-up plan may vary depending on the level of safety and the follow-up goals, the overall approach should remain consistent. Another recommendation is to develop a safety plan and use it to guide follow-up calls for helpseekers experiencing suicidal or homicidal thoughts, including a plan for limiting access to firearms.

References

  1. Vibrant Emotional Health. (2024). Safety Planning.
  2. Vibrant Emotional Health. (2023). Crisis Center Guidance: Follow-up with 988 Lifeline Contacts and Those Discharged from Emergency Departments and Inpatient Settings.
  3. Runyan, C. W., Brooks-Russell, A., Tung, G., Brandspigel, S., Betz, M. E., Novins, D. K., & Agans, R. (2018). Hospital emergency department lethal means counseling for suicidal patients. American Journal of Preventive Medicine, 54(2), 259–265. https://doi.org/10.1016/j.amepre.2017.10.023
  4. Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., Chaudhury, S. R., Bush, A. L., & Green, K. L. (2018). Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894–900. https://doi.org/10.1001/jamapsychiatry.2018.1776
  5. Centers for Disease Control and Prevention [CDC]. (2022). Suicide Prevention Resource for Action: A Compilation of the Best Available Evidence. Retrieved from https://www.cdc.gov/suicide/pdf/preventionresource.pdf
  6. Substance Abuse and Mental Health Services Administration [SAMHSA]. (2023). Crisis Center Guidance: Follow-up with 988 Lifeline Contacts and Those Discharged from Emergency Departments and Inpatient Settings.
  7. Vibrant Emotional Health. (2023). Violence Assessment and Threat Management Guidance.

Implementation Examples

  • In addition to safety planning, the Veterans Crisis Line offers follow-up calls to anyone who may need additional resources. There are other follow-up programs as well associated with the Veterans Crisis Line, including “Caring Letters” which mails follow-up letters to Veterans Crisis Line contacts. Caring letters have been shown to reduce the rate of suicide death, attempts, and ideation. There are also trained Veterans staffed at the Peer Support Outreach Call Center who reach out to Veterans Crisis Line contacts, and studies show that Veterans Crisis Line contacts involved in the peer mentorship program are more likely to keep their appointments and access additional treatment.
  • Supported by grant funding from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), the Colorado Follow-Up Project is a multi-agency collaborative effort to support effective care transition services. The Follow-Up Project’s focus is on telephonic caring contacts made to patients discharged from an emergency department after experiencing suicidal ideation and/or behavior, self-harm, or other mental health or substance use crises. Colorado’s state crisis hotline provider and hub for the Colorado 988 Lifeline provides this service 24/7. This partnership ensures patients are connected with experienced follow-up specialists who are trained in safety assessment, harm reduction, local resource linkage, and goal setting. Data from the Follow-Up Project indicates a reduction in service barriers and an increase in connections to post-discharge resources. As of 2023, there were 71 emergency departments from across Colorado referring clients to the program, resulting in over 10,000 people receiving follow-up services within the last reported year.

Implementation Resources

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